The Growing Evidence Base for Surgical Care
There is increasing interest in the provision of essential surgical care as part of public health policy in low- and middle-income countries (LMICs). Relatively simple surgical interventions have been shown to effectively prevent death and disability. Over the past decade, a substantial body of research has examined the cost-effectiveness of these surgical procedures, comparing them to standard public health interventions.
Cost-Effectiveness of Common Surgical Procedures
A comprehensive review of the published literature identified 27 studies representing 64 LMICs over a 16-year period. The studies evaluated the cost-effectiveness of a range of surgical interventions that could be made available at the district hospital level, including:
- Cataract surgery: Cost per disability-adjusted life year (DALY) averted ranged from $5.06 to $106.00.
- Elective inguinal hernia repair: Cost per DALY averted ranged from $12.88 to $78.18.
- Male circumcision: Cost per DALY averted ranged from $7.38 to $319.29.
- Emergency cesarean section: Cost per DALY averted ranged from $18 to $3,462.00.
- Cleft lip and palate repair: Cost per DALY averted ranged from $15.44 to $96.04.
These surgical interventions were found to be highly cost-effective, often comparing favorably to standard public health interventions such as oral rehydration therapy ($1,062.00 per DALY), vitamin A supplementation ($6.00-$12.00 per DALY), breastfeeding promotion ($930.00 per DALY), and HIV antiretroviral therapy ($922.00 per DALY).
The Value of Investing in Surgical Care
The evidence suggests that simple surgical interventions that are life-saving and disability-preventing should be considered as part of public health policy in LMICs. Investing in surgical care and integrating it with other public health measures at the district hospital level is likely to be a more effective approach than single-disease strategies.
A small district hospital with basic surgical services was found to be highly cost-effective, with a cost of $0.93 per DALY averted. Larger hospitals offering emergency and trauma surgery were also cost-effective, with a cost per DALY averted ranging from $32.78 to $223.00.
Evaluating the Cost-Effectiveness of Surgery Across LMICs
Building on the existing evidence, a recent systematic review synthesized the most current data on the cost-effectiveness of surgical interventions in LMICs, published between January 2013 and January 2023. The review identified 87 unique studies from 23 countries, with a focus on China, Thailand, Brazil, and Iran, which accounted for over 55% of the evidence.
Comprehensive Analysis of Cost-Effectiveness Ratios
The review computed and compared the average cost-effectiveness ratios (ACERs) for different surgical procedures across LMIC settings. The findings reinforce the growing body of evidence that investments in surgery are economically smart:
- Overall, the median ACERs ranged from $17 per DALY for laparotomies to $170,186 per DALY for bariatric surgeries.
- Most of the ACER estimates (89%) were classified as cost-effective, and 76% were considered very cost-effective based on the World Health Organization’s thresholds.
- In lower-middle-income countries, 84% of the estimates were very cost-effective, and 95% were cost-effective.
- Even in low-income countries, 62% of the estimates were very cost-effective, and 92% were cost-effective.
These findings demonstrate that a wide range of surgical interventions, from low-complexity procedures to more advanced surgeries, can be highly cost-effective in resource-constrained settings.
Comparing Surgical Interventions to Public Health Interventions
The review also compared the cost-effectiveness of surgical interventions to common traditional public health interventions. Many high-volume, life-saving, low-complexity surgical procedures, such as laparotomies, cesarean sections, glaucoma surgery, amputations, inguinal hernia repair, and appendectomies, were found to be as cost-effective or more cost-effective than interventions like oral rehydration therapy, tuberculosis vaccination, expanded immunization programs, school feeding programs, family planning services, and HIV antiretroviral therapy.
The Need for Expanded Evidence Generation
While the existing evidence strongly supports the cost-effectiveness of surgical care in LMICs, the review also identified several important gaps:
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Limited Geographical Spread: The majority of the evidence came from a small number of upper-middle-income countries, with limited representation from lower-income settings, particularly in sub-Saharan Africa.
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Lack of Breadth in Surgical Procedures: Nearly 40% of the included studies focused on just eight surgical procedures, leaving many high-volume, life-saving procedures underrepresented.
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Insufficient Evidence to Inform Surgical Planning: The available cost-effectiveness data is often not directly applicable beyond the specific healthcare systems studied, limiting its usefulness for decision-makers engaged in national surgical planning and the development of universal health coverage benefit packages.
To address these gaps, a concerted effort is needed to generate more high-quality, locally grounded cost-effectiveness evidence across a wider range of surgical interventions and LMIC settings. This will provide the necessary information to guide contextual surgical policy formulation, implementation, and evaluation, ultimately supporting the scale-up of surgical care and improving population health outcomes.
Conclusion: Surgery as a Cost-Effective Component of Universal Health Coverage
The growing body of evidence clearly demonstrates that investments in surgical care represent a cost-effective and economically smart approach to improving health outcomes in resource-constrained settings. While challenges remain in terms of generating more comprehensive data to inform decision-making, the existing research reinforces the critical role that surgical interventions should play as part of universal health coverage strategies in low- and middle-income countries.
By prioritizing the integration of essential surgical services into broader public health initiatives, policymakers and healthcare stakeholders can unlock the significant health and economic benefits that surgical care can provide. As countries continue to develop national surgical plans and expand access to universal healthcare, the cost-effectiveness evidence can guide the efficient allocation of resources and the identification of high-impact surgical “best buys” to maximize population-level impact.
